My work is all about improving health and health care through knowledge. It spans medical publishing to community health, taking in technology and innovation, and is influenced by growing up in a working-class community. I share insights from all of the above through public speaking.

Jun 21 When Problems Become Assets

I read the Eleven Principles for Creating Health through the lens of Lankelly Chase’s mission to tackle severe and multiple disadvantage. Enduring physical and mental health problems are among the most serious harms associated with combinations of homelessness, drug misuse, violence and abuse. Whether this is an association of cause or effect is rarely clear cut (or even helpful to try and fathom), which speaks to one of the principles, ‘embrace complexity’.

It would be possible for me to map our organisational experience quite comprehensively against the eleven principles. Indeed, we have developed very similar lists that guide our actions, behaviours and decision-making. What I want to share here though is a single insight that came strongly to mind as I reflected on the report.

Co-production is an idea with currency in the UK but one that has steadily lost value through inflated use. The language of co-production has been sprayed across innumerable strategy documents without disturbing power dynamics in any discernible way. The relationship between the purchasers and providers of services continues to set the parameters of what can be offered to end users. In this context, Holy Cross Centre Trust (HCCT) is a striking example of an organisation that has sought to reassert the radical intent of co-production by allowing themselves to be shaped by the core relationship with their end users.

HCCT works with people who face homelessness, drug misuse and mental illness. These are all problems that correspond to classes of professional, each of whom brings a particular expertise, a ‘way of working’, a lexicon, and a historically informed culture. They give the people with whom they work different names – resident, client in recovery, patient – and they tend to view the problem in which they specialise as primary, with other problems as secondary or contributory.

Almost inevitably in such a system, the priorities of professionals often don’t align well with those of people receiving their support, especially where there is strong purchaser control. The result is that people feel ‘done to’ by systems that that seem more preoccupied with their own priorities and targets. Some research we published last year showed that only a third of people facing multiple disadvantages thought they could really count on their support worker to listen to them, and a mere 14% thought they could really count on their support worker to help in a crisis.

It was the realisation of how broken this system has become that caused HCCT to seek a new relationship with the people they support. This relationship is summed up nicely by one of the workers:

“There is acknowledgement that it is part of the human condition that we all actively give and receive, on both an individual and institutional level. We all need to contribute and define the world around us.”

This appeal to the human condition reveals the degree to which the act of receiving support has become almost a badge of shame across an inequality divide, with the receiver labelled ‘vulnerable’, ‘not coping’ and of course ‘dependent’. In response to this, HCCT has modelled a support culture in which those using the service and staff members are both viewed as part of a learning environment, where both are contributing to the other’s growth and development, both are giving each other opportunities to contribute, both are changed by the relationship. The vulnerability of the human condition is shared.

An important corollary of this model is what it means for the staff themselves. It would be impossible to achieve such reciprocity if the team were to maintain its own hierarchy of expertise, knowledge or experience. In the words of another worker, it requires a wholesale effort “to move away from an attitude which says that if someone has a position of power, qualifications or work experience, their contribution is intrinsically more valuable than that of someone without those things”.

All of which reminds me of the sociologist Richard Sennett’s attempt to grapple with what he calls the “riddle” of achieving autonomy in a relationship of dependency. He writes: “Autonomy […] is not simply an action; it requires also a relationship in which one party accepts that he or she cannot understand something about the other. The acceptance that one cannot understand things about another gives both standing and equality in the relationship”. In other words, autonomy can still exist across an inequality divide when the terms of exchange are defined by mutual dependency, where it is recognised that neither can act without the knowledge and contribution of the other.

This brings me to the insight that came strongly to mind when I read the Eleven Principles and which was articulated by HCCT’s CEO, Sam Hopley. He described someone whose regular mental health crises were gradually revealed to be a learned (and entirely logical) means of gaining attention and company during periods of intolerable loneliness. He reflected: ‘if your problem is your biggest asset, then you grow your problem’.

A great deal of emphasis is placed by co-production practitioners on a shift from deficit-based to asset-based thinking. The idea being that if people are viewed in terms of what they have, rather than what they lack, then this is inevitably more empowering. What Hopley and Sennett remind us is that there is always an exchange taking place, that these assets are always being traded. And it is the terms of that exchange that are critical because they determine what can be exchanged or traded. The eleven principles suggest new terms of exchange: acknowledging the presence of power imbalances and that no one can do it alone, sharing power, embracing complexity, building the right team. On current terms, service users have no option but to trade their problems. And this is because workers themselves are forced to trade their ability to solve problems. When permission to say ‘I don’t know’ is denied, workers are forced to operate in a hierarchy of expertise.

The irony here is that when faced with complexity we are conditioned to reach for more and more expertise, whereas HCCT’s lesson suggests we should be reaching for more humility. Quite how we scale relationships of humility turns out to be a deeply systemic question. In our current system, the purchaser wants certainties, the provider wants the contract, and the end user wants to be heard. A provider who acknowledges that they don’t already understand the problems of their potential end users, that they need to hear from them first, is going to find that a very hard sell.

Changing this dynamic will take considerable courage from providers willing to lose contracts. Their chief ally should be the users of their services, but when faced with such power imbalances philanthropy also has to step into the fray, underwriting the risk as fellow-travellers. Yet even the phrase ‘underwriting the risk’ isn’t quite right, implying as it does only another kind of transaction or even expertise on the part of philanthropy. The depth and complexity of this challenge suggests a very different behaviour and mindset, one which disrupts the dynamic by modelling the eleven principles.

- Julian Corner

Since 2011, Julian Corner has been Chief Executive of Lankelly Chase, a UK charitable foundation focused on tackling severe and multiple disadvantage. Previous roles include Chief Executive of the mental health charity, Revolving Doors Agency, and lead author of the UK Government’s first report on reducing reoffending by ex-prisoners.